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. �� `{Policy Pravislans; wc oa o 0 0 o A) � <br /> 42 <br /> Rx INFORMATION PAGE <br /> wE WORKERS COMPENSATION AND EMPLOYERS LIABIL.lTY POLICY � <br /> I INSURER: SEE AT°PACHED EP7DORSEMEN`I' <br /> NCCI Company Number: 14974 THE <br /> Company Code; 9 <br /> TWTN CITY E'II2E INSUItAl�f� COMPANY T5 REQIIIRSD HARTF(JRD <br /> BY LAVP TO PROVIDB ITS POLICY80LDER3 WTTI3 CERTAIIY <br /> ACCIDBNT PREVEN'PION 3ERVICES AT NO ADDTTIONAL CO3T AS REQIIIRBD 8Y ARK. CODB <br /> ' ANN. `11-9-409(D) Ai�ID ROLE 32. Ili' YOV WOIILD LTKE MQRE TNFORIKATION, CALL <br /> m 'THE HAR'I'&'ORI?, L033 CONTROL DEPARTM�'NT� BARTFORD BLAZAr CALD-2-4S, gARTFORD, <br /> � CT 06115, 1-B60-547-7767.. IE YOV fiAVE ANY QVESTI0133 A80iTT 7.'HIS RSQaIRB- <br /> , N MENT, ('�LL T� HEALTH AND BAFETY DIVISION, A,RR.AN9.A,5 WORKBR3 COIdPBNSATION <br /> Cb3�i2S3TbN AT 1-800-622-44T2. S��.� <br /> � IJaRS RENEWAL <br /> � POLICY NUINBER: s3 w� Rx4zoa o1 <br /> � Prevlous Pollcy Number: s3 wE itx4zoa <br /> HUUSINC; C.Ull"': L}H � <br /> , � 1. Nam�d Insured and MallingAddress: T� & �ssoczATES CaRPa�TZON Irrc. <br /> � (Na,, Street, Town, State, ZI p Code) (SEE ENDT) <br /> � <br /> 0 <br /> a 3 2 U 0 PLEASANT RL7N <br /> N FEIN Number: 8oa2z2695 SPRINGFIELI}, IL 62711 <br /> * State Identifieation Number{s}: ME NoT �pL <br /> � <br /> � MI, RISK ID NO: 210000000 <br /> The Named insured is: stlsc�pTER S CORP <br /> — Business of iVamed Insured: STOr�s - N o c - No �ooD oR DR <br /> = Other workplaces not shown abov�: sEE ATTACHED SCHEDi3LES ; <br /> � <br /> � 2. Policy Period: From �-�13i112 To 03/31/13 <br /> w <br /> = 12;0� a.m., Standard tfine at the insurecl's mailing address. <br /> _ Produeer"s Name: T�T z�2cot7L� & CONIPANY <br /> � <br /> ,_„ �o Box i3a�a � <br /> � <br /> — SPRTNGFIELD, IL 62791 , <br /> ' Produ�er's Cotle: 850591 <br /> � IS&LII11� OfFICB: THE HARTFY]RI} <br /> � $711 UNIVERSITX EAST T7R2VE <br /> .� <br /> �■ CT�ARLOTTE NC 28213 <br /> �"� (877) 853-2582 <br /> Tofial Estimated Annual Premlum: $269,415 <br /> — Deposit Rrernlum: <br /> Palicy Minimum Premlum:�1, 150 IL (INCLLJDES INCRE:�SEL1 T�IMIT MIN. PREM.) <br /> � Audi#Period: �U� Installment Term: <br /> � <br /> � <br /> The pnlicy Is not binding unless countersigned by aur autharized representative. � <br /> � Countersigned by � <br /> Autharized Representative Date , <br /> Form WC DO Ob 01 A (1� Printed In U,S,A, Page 1 (Cantinued on next page) � <br /> Pracess Qate: o3/zo/i2 Policy Explratlon Date: a�/31/13 <br /> uw CQPY ' <br />